NURSE-455 ATI MEDSURGE Exam
Questions 2023 UPDATED
EXAM
Cardiovascular & Hematology
1. A nurse is assessing a client who is 12 hours postoperative
following a colon resection. Which of the following findings
should the nurse report to the surgeon?
A. Heart rate 88/min
B. Blood pressure 118/72 mm Hg
C. Temperature 38.6°C (101.5°F)
D. Urine output 40 mL/hr
Answer: C
Rationale: An elevated temperature (38.6°C/101.5°F) in the
early postoperative period can indicate an infection or other
complications like atelectasis or wound infection, and should
be reported to the surgeon. The other vitals are within
acceptable ranges.
2. A client with heart failure has a new prescription for
carvedilol. Which assessment finding would require the nurse
to hold the dose and contact the provider?
A. Heart rate 52 bpm
B. Blood pressure 110/68 mm Hg
, C. Weight gain of 0.5 kg (1.1 lb) in 24 hours
D. Complaints of mild fatigue
Answer: A
Rationale: Carvedilol is a beta-blocker that can cause
bradycardia. A heart rate below 60 bpm is a typical holding
parameter.
3. A client with angina pectoris is prescribed nitroglycerin
sublingual. What instruction should the nurse provide?
A. "Take one tablet every 15 minutes for up to 3 doses."
B. "Swallow the tablet with a full glass of water."
C. "Store the tablets in a clear glass container."
D. "Take the medication at the same time daily."
Answer: A
Rationale: Nitroglycerin sublingual should be taken at the
onset of chest pain. If pain persists after 5 minutes, the client
should call 911. The client can take up to 3 tablets, 5 minutes
apart.
4. A client receiving furosemide complains of muscle
weakness and cramps. Which laboratory value requires
immediate attention?
A. Sodium 140 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes
potassium wasting. A potassium level of 2.8 mEq/L is critically
, low (hypokalemia) and can cause muscle weakness and
cardiac dysrhythmias, requiring immediate attention.
5. A nurse is providing discharge teaching to a client with a
new diagnosis of hypertension. Which statement by the client
indicates understanding?
A. "I will stop my medication when my blood pressure is
normal."
B. "I will check my blood pressure daily and keep a log."
C. "I can resume smoking as long as I take my medication."
D. "I will restrict sodium only when I feel symptomatic."
Answer: B
Rationale: Daily blood pressure monitoring and logging
helps track treatment effectiveness and medication
adherence.
6. A nurse is caring for a client who is receiving a blood
transfusion. The nurse observes bounding peripheral pulses,
hypertension, and distended jugular veins. Which medication
should the nurse anticipate administering?
A. Epinephrine
B. Diphenhydramine
C. Acetaminophen
D. Furosemide
Answer: D
Rationale: These signs indicate fluid overload (Transfusion-
Associated Circulatory Overload, or TACO). Furosemide is a
diuretic that helps remove excess fluid.
7. What are the classic triad findings in aortic stenosis?
, A. Fever, tachycardia, and hypotension
B. Syncope, angina, and dyspnea on exertion
C. Palpitations, cough, and peripheral edema
D. Headache, epistaxis, and blurred vision
Answer: B
Rationale: The classic triad includes syncope (from decreased
cardiac output), angina (from increased oxygen demand), and
dyspnea on exertion (from left ventricular failure).
8. A client with heart failure is prescribed digoxin. Which of
the following is a sign of digoxin toxicity?
A. Tachycardia
B. Hypertension
C. Anorexia and nausea
D. Hyperkalemia
Answer: C
Rationale: Early signs of digoxin toxicity include
gastrointestinal symptoms like anorexia, nausea, and
vomiting, as well as visual disturbances (e.g., yellow-green
halos) and bradycardia.
9. A client is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate the therapeutic effect of
this medication?
A. aPTT
B. INR
C. Platelet count
D. Hemoglobin
Answer: B
Questions 2023 UPDATED
EXAM
Cardiovascular & Hematology
1. A nurse is assessing a client who is 12 hours postoperative
following a colon resection. Which of the following findings
should the nurse report to the surgeon?
A. Heart rate 88/min
B. Blood pressure 118/72 mm Hg
C. Temperature 38.6°C (101.5°F)
D. Urine output 40 mL/hr
Answer: C
Rationale: An elevated temperature (38.6°C/101.5°F) in the
early postoperative period can indicate an infection or other
complications like atelectasis or wound infection, and should
be reported to the surgeon. The other vitals are within
acceptable ranges.
2. A client with heart failure has a new prescription for
carvedilol. Which assessment finding would require the nurse
to hold the dose and contact the provider?
A. Heart rate 52 bpm
B. Blood pressure 110/68 mm Hg
, C. Weight gain of 0.5 kg (1.1 lb) in 24 hours
D. Complaints of mild fatigue
Answer: A
Rationale: Carvedilol is a beta-blocker that can cause
bradycardia. A heart rate below 60 bpm is a typical holding
parameter.
3. A client with angina pectoris is prescribed nitroglycerin
sublingual. What instruction should the nurse provide?
A. "Take one tablet every 15 minutes for up to 3 doses."
B. "Swallow the tablet with a full glass of water."
C. "Store the tablets in a clear glass container."
D. "Take the medication at the same time daily."
Answer: A
Rationale: Nitroglycerin sublingual should be taken at the
onset of chest pain. If pain persists after 5 minutes, the client
should call 911. The client can take up to 3 tablets, 5 minutes
apart.
4. A client receiving furosemide complains of muscle
weakness and cramps. Which laboratory value requires
immediate attention?
A. Sodium 140 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mEq/L
Answer: B
Rationale: Furosemide is a loop diuretic that causes
potassium wasting. A potassium level of 2.8 mEq/L is critically
, low (hypokalemia) and can cause muscle weakness and
cardiac dysrhythmias, requiring immediate attention.
5. A nurse is providing discharge teaching to a client with a
new diagnosis of hypertension. Which statement by the client
indicates understanding?
A. "I will stop my medication when my blood pressure is
normal."
B. "I will check my blood pressure daily and keep a log."
C. "I can resume smoking as long as I take my medication."
D. "I will restrict sodium only when I feel symptomatic."
Answer: B
Rationale: Daily blood pressure monitoring and logging
helps track treatment effectiveness and medication
adherence.
6. A nurse is caring for a client who is receiving a blood
transfusion. The nurse observes bounding peripheral pulses,
hypertension, and distended jugular veins. Which medication
should the nurse anticipate administering?
A. Epinephrine
B. Diphenhydramine
C. Acetaminophen
D. Furosemide
Answer: D
Rationale: These signs indicate fluid overload (Transfusion-
Associated Circulatory Overload, or TACO). Furosemide is a
diuretic that helps remove excess fluid.
7. What are the classic triad findings in aortic stenosis?
, A. Fever, tachycardia, and hypotension
B. Syncope, angina, and dyspnea on exertion
C. Palpitations, cough, and peripheral edema
D. Headache, epistaxis, and blurred vision
Answer: B
Rationale: The classic triad includes syncope (from decreased
cardiac output), angina (from increased oxygen demand), and
dyspnea on exertion (from left ventricular failure).
8. A client with heart failure is prescribed digoxin. Which of
the following is a sign of digoxin toxicity?
A. Tachycardia
B. Hypertension
C. Anorexia and nausea
D. Hyperkalemia
Answer: C
Rationale: Early signs of digoxin toxicity include
gastrointestinal symptoms like anorexia, nausea, and
vomiting, as well as visual disturbances (e.g., yellow-green
halos) and bradycardia.
9. A client is prescribed warfarin. Which laboratory value
should the nurse monitor to evaluate the therapeutic effect of
this medication?
A. aPTT
B. INR
C. Platelet count
D. Hemoglobin
Answer: B
